Vocal health of teacher: phonoaudiologic intervention in primary health care

Abstracts

OBJETIVO: apresentar uma ação de promoção a saúde vocal dos professores de três escolas municipais situadas no Distrito Sanitário III, em Recife-PE, no âmbito da Atenção Primária à Saúde - APS. MÉTODO: foi aplicado um questionário sobre o histórico vocal dos professores e realizadas seis oficinas de voz, com o intuito de sensibilizar os docentes sobre a importância dos cuidados com a voz e incentivar a prática dos exercícios vocais preventivamente como ação cotidiana dentro do processo de trabalho. Por fim, foi aplicado um questionário para avaliar a percepção dos docentes em relação às oficinas. RESULTADOS: as educadoras encontravam-se na faixa etária de 17-55 anos, tinham 10,4 anos em média de exercício profissional e 96,3% relatou a percepção de problemas com a voz ou fala, sendo que quanto maior a frequência de aparecimento do problema, maior era o tempo de exercício profissional, a jornada de trabalho e a idade. Os depoimentos foram positivos em relação às oficinas, sendo que 80% das docentes referiu melhora no desempenho profissional e 93,3% afirmou que continuará realizando os exercícios, mas apontaram a falta de tempo como principal dificuldade para realização dos exercícios rotineiramente. CONCLUSÃO: estes resultados identificam a importância da introdução de ações voltadas à saúde do professor com o intuito de amenizar os efeitos do trabalho sobre sua saúde, e a inserção do fonoaudiólogo na APS a fim de facilitar estas ações na prática cotidiana. A utilização do espaço escolar permite configurá-lo como espaço social para tomada de consciência, reflexão, discussão sobre as condições de trabalho e como um ambiente saudável.

Promoção da Saúde; Saúde Vocal; Professor; Educação em Saúde; Atenção Primária à Saúde

ORIGINAL ARTICLES

Vocal health of teacher: phonoaudiologic intervention in primary health care

Ivana Arrais de Lavor Navarro Xavier^I; Ana Célia Oliveira dos Santos^II; Danielle Maria da Silva^III

^ISpeech Therapist; Specialization in Family Health from the School of Medical Sciences at University of Pernambuco – FCM / UPE

^IINutritionist, Associate Professor in the Institute of Biological Sciences at University of Pernambuco – UPE; Tutor and Preceptor of Integrated Multidisciplinary Residency in Family Health at University of Pernambuco – UPE; PhD in Biological Sciences from Federal University of Pernambuco – UFPE

^IIISpeech Therapist; Tutor and Preceptor of Integrated Multidisciplinary Residency in Family Health at University of Pernambuco – UPE, Specialization in Language from Federal University of Pernambuco – UFPE; Specialization in Oral Motricity with focus on Dysphagia, from Integrated School of Recife – FIR; Master in Public Health from Federal University of Pernambuco – UFPE

^{Mailing address}

ABSTRACT

PURPOSE: to promote the vocal health of teachers from three municipal schools situated in the III Sanitary District, in the city of Recife, PE, Brazil, which is in the sphere of PHC (Primary Health Care).

METHOD: a questionnaire on vocal history of teachers was answered in six voice workshops to raise awareness among teachers about the importance of voice care and to encourage the practice of vocal exercises as a preventative action in their daily process of teaching. In the last meeting a questionnaire was presented to assess the result of the workshops.

RESULTS: the teachers were aged 17-55 years, were on average 10.4 years of professional experience and 96.3% reported problems with the perception of voice or speech, and the higher the frequency of occurrence of the problem, was the largest exercise time professional, working day and age. The statements were positive about the workshops, with 80% of teachers reported improvement in work performance and 93.3% said it will continue doing the exercises, but pointed out the lack of time as the main difficulty in the exercises routinely.

CONCLUSION: these results identify the importance of introducing health actions of the teacher in order to mitigate the effects of work on their health, and the insertion of a speech therapist in the PHC to facilitate these actions in everyday practice. The use of school space lets set it up as a space for social awareness, reflection, discussion about working conditions as well as a healthy environment.

Keywords: Health Promotion; Vocal Health; Teachers; Health Education; Primary Health Care

INTRODUCTION

Primary Health Care (PHC) represents the first contact with the health care network within the health system. It is mainly characterized by continuity and comprehensive care, as well as by the way assistance is coordinated within the system itself, with attention being centered on the family, supervision, community involvement and the cultural competence of professionals. Its essential attributes can be stated as follows: the first point of contact of the individual with the health system, continuity and comprehensive care and the coordination of care within the system¹.

The Ministry of Health established the FHSC (Family Health Support Centers) by enacting GM Directive no. 154 on 24th January, 2008², with the aim of broadening the scope of Primary Health Care in Brazil. This involved expanding the areas of problem-solving, territorialization and regionalization as well as the range of APS activities An FHSC must consist of a team in which professionals from different areas of knowledge work together with professionals from Family Health teams by sharing and supporting health practices within their spheres of responsibility.

The FHSC must comply with some of the PHC guidelines which involves knowing about the following: interdisciplinary and intersectional activities; continuous health education for professionals and the public; the development of the notion of the territory; comprehensiveness, social participation and public education; and the promotion of health and humanization. It should also be borne in mind that there are several intervention procedures in the territory – for example, in carrying out health projects in the territory; giving support to groups; educational work and social inclusion; confronting situations of violence and anti-social behavior; and activities carried out with public facilities³.

One key example of social facilities where the health team operates, is the school. Health policies recognize the school space as being suited to practices for promoting health, taking preventive measures and providing education in health where the educational processes are divided between building healthier lives and creating an environment that is suited to health⁴. However, there are few activities that are geared towards the health and lives of the teacher, who is mainly viewed as a mediator or partner in activities carried out to improve the health of students, families and the community⁵.

Teaching makes great demands on the voice and as a result, a number of vocal problems have been found among those who exercise it a good deal. Few people have any vocal preparation for its professional use. There is only superficial knowledge with regard to taking care of the voice and little attention has been paid to complaints, or signs and symptoms of vocal health-illness or the difficulties of noticing, interpreting and confronting its determining factors. The voice tends to be used a lot in adverse working conditions and organizational environments and it is clear that people hesitate, or are reluctant, to seek specialized treatment for it⁶.

The voice of the teachers is referred to by themselves as one of the main assets for work. However, owing to a lack of previous vocal training and a number of conditions that are unfavorable to teaching, the teacher is a professional at risk of developing a voice problem. The responsibility of conveying knowledge, giving students cultural training and fulfilling the school curricula, often leads teachers to play down the importance of their vocal problems and only to seek help when it becomes almost impossible for them to speak audibly^5,6.

In the phonoaudiological activities that affect teachers' vocal health, it is necessary to broaden the perception and conduct an analysis of the determining factors in the area of vocal health-illness by replacing the pathology/treatment axis with health/promotion, and including factors from everyday life. This also includes ¨quality¨, which is an essential feature required for analyzing dysphonia in teaching work and involves two key factors – poor working conditions and a poor standard of life with regard to the voice⁷. Once the question of phonoaudiological performance is clearly in focus, the voice workshops and group practice can become a social space where interventions are possible⁸.

The point of departure for this study were the activities carried out by FHMR (Family Health Multiprofessional Residency), by means of the activities of the speech therapist – before FHMR had been implemented in the city of Recife. This was based on reflections outlined in the policies cited above and after noting that the literature has very little to offer on the question of promoting vocal health or preventing vocal alterations^9,10. The purpose of this study was to select a real-life situation to outline an activity concerning the promotion of health from the perspective of FHSC, which involved groups of teachers and their perceptions of the activity that was carried out.

METHOD

The research study was approved by the Research Ethics Committee of the University of Pernambuco (CEP-UPE), CAAE 0094.0.097.000.10.. All the participants signed the consent form and declared that they authorized the publication of the results.

It was a study of a descriptive nature, adopting a quantitative-qualitative approach, that was conducted in three municipal schools situated in the boroughs of Córrego do Jenipapo, Macaxeira and Morro da Conceição, located in the Health District III in Recife (State of Pernambuco).

At first, the study comprised 27 participants, all of whom were female. However, as the workshops proceeded, one of the schools requested to withdraw from the research owing to problems over the timetable of the teachers and as a result, only two meetings were held at that teaching establishment. Despite this, the data collected in the first stage of the research were retained so that they could be used to characterize the initial sample.

Six workshops were carried out in each of the schools with the aim of improving the vocal health of the teachers. The workshops took place every fortnight and were held in the school space itself at the end of the school activities; they followed a timetable that was arranged with the director of the school and the staff.

In the first workshop which lasted for an hour, the teachers answered a questionnaire called ¨vocal history¨ (Figure 1), adapted from França (2003)¹¹. The purpose of this was to find out the vocal profile of the teacher-participants so that future workshops could be planned. In this meeting, there was a discussion about voice production and speech, everyday routines and the relationship of these factors with the voice and the need to take care of the voice.

The other workshops lasted for 40 minutes and adopted the following pattern:

1) The time of the changeover from the guidelines of the previous workshop – influence of the guidelines on professional practice and the everyday difficulties experienced in carrying out the activities;

2) The use of vocal techniques used worldwide, starting out from moments of relaxation, support techniques for taking care of the voice (vocal health) and voice exercises. The objective was to show effective ways of taking care of the voice and mitigating the effects of an abuse of the voice by these professionals. The following exercises were carried out to achieve this: loud gargling with water, utterance of fricatives, vibration of the lips and tongue and humming.

3) Listening to the voice and impressions, stressing the importance of perception and self-assessment of the voice. The purpose of this was to ensure that everyone could evaluate what her voice was like at a particular moment and over a period of time; following this, reflection could be given to what had a beneficial or harmful influence on the vocal characteristics of each person. Recordings were made of the voices of teachers before and after they carried out their vocal exercises. These recordings were used for subsequent discussion with the participants about whether or not the vocal quality was better.

In the last workshop, there was a questionnaire (Figure 2) which was compiled by the authors with a view to recording the results of the way the intervention was perceived by the teachers.

Since the activity was undertaken in the PHC, there was no intention to carry out a diagnostic test or specialized monitoring but rather to concentrate on promotion, prevention and health education and encourage the practice of exercises, as an everyday anticipatory measure within the routine of the teacher's work.

The data collected from both of the questionnaires were stored in an Excel databank – Windows7 and were drawn on to conduct a descriptive quantitative analysis with a distribution of frequencies. There was also a qualitative analysis based on the replies to the questionnaires and the results of the activities that were carried out to heighten the awareness of the teachers of the need to take care of their voice. The relevant data from the study are shown in the form of Tables.

RESULTS

The 27 teachers who took part in the study were aged between 17 and 55, with an average age of 35. The average time spent in their professional career was 10.4 years, with 15 teachers (55.6%) who had been practicing teachers for less than 10 years and 12 (44.45%) who had worked for more than 10 years. With regard to their weekly workload, 19 (17.4%) worked more than 20hs, and 8 (29.6%) less than 20 hours a week.

Figure 3 shows the symptoms and vocal complaints that were most perceived by the teachers, which were: a burning sensation in the throat (85.2%), hoarseness (74.1%), a frog in the throat (or frequent cough) (70.4%) and finding it an effort to speak (66.7%).

Among the teachers, 92.5% of the teachers referred to symptoms, including some who showed them at the same time. In Table 1, there is a description of the information about the conditions referred to by the teachers and the variables related to the professional activity.

Referred having problems with the voice or speech 96.3% of the teachers, and the frequency of the variables related to professional activity is outlined in Table 2.

It can be seen that 48.1% have these problems occasionally; 37.0% frequently; 11.1% constantly and only 3.7% never experienced them.

In the group of teachers aged over 51; all stated that they had problems constantly, whereas in the group below 30, and between 30 and 40, the highest percentage of problems was in the occasional category (50% and 80% respectively). Concerning the time spent in the profession, there was a higher percentage of constant problems in the group over 11 years, whereas in the group below 10 years, a higher number had occasional problems. With regard to specific disorders, the most often mentioned were: rhinitis, (44.4%), laryngitis/pharyngitis (tonsilitis) (37.04%), sinusitis (29.63%), bronchitis and others (18.5%).

Although 74% of the teachers suffered from these disorders, only 33.3% underwent medical treatment specifically for vocal problems or ailments related to the voice, while the rest (66.7%) never had any treatment.

With regard to the question of smoking, there was a low incidence in this group with only one teacher being a regular smoker.

On the issue of the self-perception of the participants concerning the measures taken to improve their phonaudiological activities, 80% of the teachers replied that they had noticed an improvement, 6.7% said they had not noticed it and 13.3% did not answer the question. As regards the assessment of the teachers' workshops, the majority (66.7%) thought the activities were excellent and the others stated that they were good. The main benefits mentioned by the teachers were as follows: a lower rate of hoarseness (53.3%), an improvement in vocal quality (40%); a lessening of the problem over an effort to speak (20%); and a lessening of the frog in the throat problem (13.3%)

Of the total participants, 73.3% are doing the exercises suggested in the workshops on a routine basis and the rest (26.7%) are not doing them because of a lack of time. When asked about whether they intended to continue doing the exercises under supervision, 93.3% expressed a wish to continue with them and only 6.7% replied that they would not be able to continue because of a lack of time.

DISCUSSION

The sample of the research, who can be regarded as a group of people at risk of vocal alterations, made several complaints concerning the bad use of the voice. This serves as a warning of the need to seek better ways of taking care of the voice since there may be auditory signals that the voice is undergoing an alteration which require attention and hence these signals must be addressed^6,7.

Most of the symptoms increase with advancing age. All the teachers in the age group above 51 showed more than one symptom. It should also be noted that there was a link between the symptoms and the time spent in the profession and the weekly work load; there was a higher percentage among the participants with 11 or more years in the profession or who worked for over 21 hours a week.

With the support of the collected data, a study showed that hoarseness, speech tiredness, loss of voice and irritation in the throat are more common among teachers who work over 25 hours a week. This suggests that in this working group, the hourly workload factor is closely bound up with the problem of vocal impairment¹².

This finding is a warning of the need to carry out activities that can help prevent these occasional problems from becoming longstanding with the passing of time.

In the literature, it is clear that age and time spent in the profession are risk factors for teachers experiencing increased vocal problems. People with alterations in their voice are, on average, a little older than those without alterations and show the greatest signs in their thirties, since the average time for undergoing these alterations is 11 years spent in the profession^13,14. However, a number of discrepancies have been found in the literature in this area. The researchers of one study did not observe a relationship between the frequency of dysphonia and the age of the teacher or time spent in the profession. These authors believe that this was due to the fact that teachers with serious problems will be redeployed, or in other words, removed from the classroom and assigned other responsibilities in the sphere of education or perhaps even, in the more extreme cases, leave the profession altogether¹⁵.

Studies suggest that being involved for a longer time in teaching is linked to a greater frequency of voice impairments, whether they be acute or chronic. The negative symptoms and alterations to the voice increase when there is a greater workload^12,16,17.

From the accounts given by the teachers, it was evident that most of the participants suffered from vocal complaints although only a small proportion stated that they had undergone vocal therapy, which suggests that basic measures to address the problem and general health in schools, can lead to an improvement in the quality of life of these professionals.

Even when there are signs of vocal problems, the teachers continue to use their voice for the same requirements and avoid taking measures or seeking aid to alleviate the problem so that they can overcome vocally-abusive habits^6,12. Hoarseness, speech tiredness and voice defects are evident, however, in the fact that teachers give greater priority to understanding how to keep students under control than ensuring that they take care of their voice in the ways recommended by the therapists¹⁵.

Another important finding in this study is that 18.5% of the teachers performed some kind of vocal technique, which shows that many do not have any knowledge of how to use or take care of their voice and those that do, fail to make use of it on a day-to-day basis.

In assessing the participants' workshop, it is worth drawing attention to the comments made by one of them:

¨These workshops were very important because they made me aware of how much I need to take care of my voice, because we use it as an instrument for our work. It is really essential to know how to use the voice in a suitable way and carry out exercises correctly. It was a learning experience that affected my whole life. I really appreciated it ! (AMS)¨

In spite of their positive assessment of the workshops, some teachers thought they had to give them up owing to a lack of time or a feeling of embarrassment in taking part in group activities; one of them even mentioned the difficulty of doing some of the exercises.

Teachers have a very limited amount of time and most of them work in more than one school and have a family with children¹⁵. Nonetheless, most of the participants of this study stated that they were carrying out the exercises recommended in the workshops. The account given by one of the teachers suggests that there is even a need for phonoaudiological work in the school:

¨I would like to see more workshops of this kind set up. Since we don't have much time, phonoaudiology in the school can provide us with a period for practising the exercises (DRS)¨.

This statement by the teacher (given above) shows that the workshops were well liked and there was a general perception by the participants of the importance of doing the exercises. This was shown by the fact that 93.3% stated that they would continue doing the exercises even after the intervention and only 6.7% replied that they would not continue with the exercises because of a lack of time.

¨They were good recommendations and the results are obtained automatically. I've benefited a lot in terms of voice quality. I will need to have more sessions because we need to acquire a routine and a stimulus. It will encourage us to practice in a routine way" (AEO)

It is clear that their situation and work routine makes it hard for teachers to practise activities concerned with vocal health, even though they are fully aware of its importance for them.

¨.... In my view, this kind of activity should be more often found in schools because as we use the voice as a part of our profession, we must take care of our working instrument. Added to this, vocal health is a general requirement in society because people have to be aware that the voice is a part of the body and plays a role in the way the body functions" (JRGB) ¨

On the basis of these teachers' comments, it is evident that they are interested in the activities that they carry out as forming a part of their working routine, as well as their perception of the importance of taking care of their voice to ensure a better professional performance.

Activities carried out with teachers in health education have yielded good results, particularly when the activity is undertaken in a group, since the difficulties experienced by teachers are similar^18,19. Soon, it will be possible for health measures such as groups undergoing experiences with their voice, to be characterized as important spaces for reflection and for changing the relationship that exists between the work and health of the teacher²⁰.

However, it should be noted that although the data examined have had a positive effect, there remain questions concerning the way working conditions make it difficult to maintain a healthy voice during one's professional career. As has been stressed in other research studies, the question of whether or not to seek health assistance, is combined with other factors that go beyond the perception of ailments and involve the possible influence of the school workplace on the decision of the teacher to look for aid as a result of voice problems²¹.

Another factor that both assisted and impeded the introduction of Speech Therapist to schools was their link to FHU (Family Health Units) in the area. In schools where there was already some kind of intervention by FHU, there was a greater degree of acceptance of the workshops since there was more belief in the value of the activities they carried out and more regularity in their use by teachers. This point strengthens the need for intersectoriality which entails integration between the health sectors and education and the accountability of the health team for the assigned area and the activities carried out in social amenities, including the schools.

Since the teacher is a worker, it is essential to regard the school as a working environment with its own structure and working conditions that influence and determine the degree of the health/illness of the working teacher.

When it is taken into account that issues regarding the health of teachers go beyond problems with the voice, it should be noted that there is a need to include multi-professional teams in schools. In addition, it is recommended that the PSE should not only be used for the students but for the whole school with activities that can help the school community, including parents, teachers and other professionals, as well as students; this will also make the working environment a more healthy place.

CONCLUSION

The majority of teachers have made some reference to problems with their voice or speech but few have sought asssistance for them. The intervention of voice workshops for teachers has had positive results because most teachers realize the importance of taking care of the voice to achieve a better vocal performance, as well as in their professional activities. They also stated that they would continue to do the exercises after the intervention.

The group work allowed teachers to exchange experiences and was a motivating factor. The intervention of the workshop in the school space has enabled teachers to participate more easily and also to be aware of the need and importance of carrying out exercises and taking part in them since previously most of them had complained about the lack of time.

These results show the importance of carrying out activities concerned with the health of teachers with the aim of mitigating the effects of work on health and introducing phonoaudiology in the APS with the aim of enabling these activities to occur in everyday practice. The use of school space allows it be converted into a social space for social awareness, reflection and discussion about working conditions and a way to achieve a healthy environment.

From this perspective, it is important to take note of recommendations for improving health in schools that are guided by comprehensiveness, interdisciplinary and intersectoriality. In particular, it is essential to forge close links between the schools and family health teams, as well as NASF, with a view to achieving comprehensive health for teachers and the school community.

REFERENCES

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2. Brasil. Portaria nº 154, de 24 de janeiro de 2008. Cria os Núcleos de Apoio à Saúde da Família – NASF [Internet]. [acesso em 2010 abr]. Disponível em: http://dab.saude.gov.br/nasf.php

3. Ministério da Saúde (Brasil), Secretaria de Atenção à Saúde, Departamento de Atenção Básica, Cadernos de Atenção Básica, n27. Diretrizes do NASF – Núcleo de Apoio a Saúde da Família. Brasília: Ministério da Saúde; 2009. 160p.

4. Projeto Promoção da Saúde. Secretaria de Políticas de Saúde/MS. A promoção da saúde no contexto escolar. Rev Saúde Pública. 2002;36(2):533-5.

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11. França MC. Voz em telejornalismo: fonoaudiologia e repórteres de TV. In: Kyrillos LR. Fonoaudiologia e telejornalismo: relatos de experiência na rede globo de televisão. Rio de Janeiro: Revinter; 2003. p. 3-16.

12. Araújo TM, Reis EJFB, Carvalho FM, Porto LA, Reis IC, Andrade JM. Fatores associados a alterações vocais em professoras. Cad. Saúde Pública [Internet]. 2008 [acesso em 2010 ago];24(6):1229-38. Disponível em: http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S0102-311X2008000600004

13. Ortiz E, Lima EA, Costa EA. Saúde vocal de professores da rede municipal de ensino de cidade do interior de São Paulo. Rev. Bras. Med. Trab. 2004;2(4):263-6.

14. Fuess VLR, Lorenz MC. Disfonia em professores do ensino municipal: prevalência e fatores de risco. Rev Bras de Otorrinolaringol. [Internet]. 2003 [acesso em 2010 set];69(6):807-12. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0034-72992003000600013

15. Ceballos AGC, Carvalho FM, Araújo TM, Reis EJFB. Avaliação percepto-auditiva e fatores associados à alteração vocal em professores. Rev. Bras Epidemiologia. 2001;14(2):285-95.

16. Luchesi KF, Mourão LF, Kitamura S, Nakamura HY. Problemas vocais no trabalho: prevenção na prática docente sob a óptica do professor. Saúde e Soc. [Internet]. 2009 [acesso em 2010 set];18(4):673-81. Disponível em: http://www.scielo.br/scielo.php?pid=S0104-12902009000400011&script=sci_arttext

17. Souza CL, Carvalho FM, Araújo TM, Reis EJFB, Lima VMC, Porto LA. Fatores associados a patologias de pregas vocais em professores. Rev Saúde Pública. 2001;45(5):914-21.

18. Azevedo LL, Vianello L, Oliveira HGP, Oliveira IA, Oliveira BFV, Silva CM. Queixas vocais e grau de disfonia em professoras do ensino fundamental. Rev Soc Bras Fonoaudiol. 2009;14(2):192-6.

19. Simões-Zenari M, Latorre MRDO. Mudanças em comportamentos relacionados com o uso da vozapós intervenção fonoaudiológica junto a educadoras de creche. Pró-Fono R Atual. Cient. 2008;20(1):61-6.

20. Silverio KCA, Gonçalves CGO, Penteado RZ, Vieira TPG, Libardi A, Rossi D. Ações em saúde vocal: proposta de melhoria do perfil vocal de professores. Pró-Fono R Atual. Cient. 2008;20(3):177-82.

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Received on: May 24, 2012

Accepted on: April 02, 2013

Conflict of interest: non-existent

Publication Dates

• Publication in this collection
  18 Sept 2013
• Date of issue
  Aug 2013

History

• Received
  24 May 2012
• Accepted
  02 Apr 2013